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" Tim Vr�,,11601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Bp`FICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> r THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X76 <br /> (Complete In Triplicate). <br /> Application is hereby made the San Joaquin Local Health District for a permit to construct <br /> •"and/or install.the work herein described. This application 'is made in compliance with San Joaquii <br /> 'County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> :TOB ADDRESS/LOCATION„ G,/, p-s. CENSUS TRACT <br /> Owner's Name lC Phone <br /> Address Y 62' W, LO VI-r,5 City <br /> Contractor's Namei _ <br /> �� License # Phone <br /> •r <br /> } TYPE OF WORK (Check).- NEW WELL/=7" DEEPEN /7 RECONDITION/? DESTRUCTION /7 <br /> ' PUMP INSTALLATION UMP REPAIR / PUMP REPLACEMENTW7 Y <br /> Other Jam' <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia:', of Well Casing 0 <br /> 4Domestic <br /> /public Driven Gauge of Casing <br /> 4 Irrigation Gravel Pack `Depth� of Grout Seal,- <br /> Cathodic Protection Aotaryy'" _ .W-Type of Grout' <br /> Disposal Other Other Information <br /> r Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contract toe <br /> Type of Pump H.P f� <br /> PUMP REPLACEMENT: F_7 State Work Done + <br /> PUMP 'REPAIR: 17 State-Work.Done— <br /> ESTRUCTION OF'WELL: Well Diameter Approximate Depth <br /> o.__. Describe Material and Procedure i <br /> � � r <br /> I hereby agree to comply with all laws and regulations ,of the .San Joaquin Local Health District <br /> and -the State of California pertaining to or regulating well cohistruction. Within FIFTEEN DAYS <br /> i after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> i WELL DRILLERS REPORT of the well and notify them before putting.the. viell in use.. The above <br /> information is true to -the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 1 PRIOR TO G&IaUTIRG AND A FINAL, INSPECTION. J <br /> SIGNED ( TITLE ti <br /> } DRAW PLOT PLAN ON REVERSE SIDE 3 <br /> r <br /> R DEPARTWT USE ONLY <br /> FHASE I <br /> APPLICATION ACCEPTED BY ( DATEl <br /> ADDITIONAL COMMENTS: <br /> . 4 PHASE-IGROUT INSPECTION - PRAS&IIJI-IFINAL INSPECTION <br /> INSPECTION- BY DATE INSPECTION B DATES-/U•-7 6 <br /> t E H 1426 Rey.._. .1-74 _ <br /> ..� 1-74 2M <br />